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m DEPARTMENT OF BUILDFNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 "
WORKER'S COMPENSATION INSURANCE AAFMAVIT
I, d�E..J L, 6&a>:;�j
(licensNC/permittee)
with a principal place of business/residence at:
757 0-t"frz RS)- / (phoney#)
(stree.Uci ty/sta tdzi p)
do hereby certify, under the pains and penalties of perjury, that:
( I am an employer providing the following workers compensation coverage for my
employees working on this job:
j s az
(Insurance Company) Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
r.
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sSCa ifnecenary to inchsdo information pertaining to all 000tmdon)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing alt the work myself.
NOTE:please be aware that wEio homcowncrs who employ pasom to do mainf,.,,,,,,�cou&ucdoa or repair work ou a dwelling of
not more than throe tails is which the homeowner reside or on tb4 grounds appurtenant thereto art not generally oowLdcred to be
cmploytn under the worker's a=pcaation Act(GL152,rs 1(5)),appliration by a homeowner for a Uccase or permit may evidence the
legal ctawa of an employer under the Woricoes Compensation AeL
I understand Thai a copy of this ctatceocal may be forwarded to the Dope t mco2 of Industrial A=dea&Of hoc of Insurance for the
coverage verification and that failurt,to s*-=oovcntgo under socUoa 25A of MGL 152 can lead to the imposition of criminal penalties
oomisting of a fine'of up to S1,500.00 and/or imprisoam--yt of up to one year and civil pcnalties in the form of a Stop Work Ord--and a
fine of 3100.00 a day against me.
For dcp=tx=%W tLO oaty
�J Permit Number
lviap# Lot#
Signature of Licenseelpermittee I Date
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
SECTION 11-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR`CONTRACTOR APPLIES FOR"BUILDING PERMIT
as Owner of the subject property
hereby authorize O �, �t=�T`� �' \ to act on
my b ,.in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
SECTION 12 CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: / Not Applicable ❑
Name of License Holder Ott 7 355-7
License Number
75- C t4 j24 /a3
Address Expiration 6ate
- 6"Z 5-(o
Signature Telephone
SECTION 13 -WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L, c. 152, §25C(6)),
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... 9v' No...... ❑
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9- PROFESSIONAL. DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRPCTURES,SUBJECT'To
CONSTRUCTION.CONTROL:PURSUANT TO 780;
Version 1.7 Commercial Building Permit May 15,2000
7. Water Supply(M.G.L. c. 40, §54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone: Outside Flood Zone ❑ Municipal ❑ On site disposal system ❑
S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property?YES
No
IF YES, describe size, type and location:
� r
' Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS`THAN 35,000
CUBIC FEET OF'ENCLQSEQ SPACE
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
}�ell Accessory Building[ ] Repairs [ ]
✓��lF �C'�� i BU) 547 f� 5ii �c� CD.NNfrC+� �W v QLi(171+J 'S G,t
SECTION$ - USE GROUP AND CONSTRUCTIOIV,TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly Io A-1 ❑ A-2 ❑ A-3 ❑ lA I ❑
A-4 ❑ A-5 ❑ 113 1 ❑
B Business ❑ 2A I ❑
E Educational ❑ 2B ( ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1.1 ❑ 1-2 ❑ 1-3 ❑ 313 ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING.BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN,USE -
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING'HEIGHT AND AREA
E IC
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTIONS
Floor Area per Floor(sf) St
ti
.sta
2nd
1st §x �
nd 3rd 3 sl
3rd 4 th
4th
Total Area (sf) Total Proposed New Construction (sf) #, t
Nil
....................................
„
Total Height(ft) 1
Total Height ft ------------------- w
N
Version 1.7 Commercial Building Permit May 15,2000
rL Ec Nort hampton
g Department
� � � 20Q2 Main Street
oom 100
Nor ha pton, MA 01060
; , �t E 587 240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1=SITE INFORMATION
1.1 Property Address:
KO`a� a �;1� (��Q
y" ` s g .ra y.� c r�afr 3 r�,• Y� aa4 Ha.;� Y.•,, '" s �
Imy xv Distrlc# CF#Dlstrlct� j
m
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�w �
Name(Print) ' Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building �, (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from b
3. Plumbing �^ Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =0 + 2 + 3 +4+ 5) G OOO"u--'lpeo ya., Check Number
This Section For Official Use Ohl
Bui,iding Permit Number: &02— ! ? Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
t ,
File#BP-2002-1008
APPLICANT/CONTACT PERSON O'Brien Construction
ADDRESS/PHONE 75 Clayton Rd. (413)536-2564
PROPERTY LOCATION 355 BRIDGE ST- 1A& 113
MAP 25A PARCEL 107 008 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid it- a55--3
Typeof Construction: BUILD STAIRCASE TO CONNECT 2 BLDGS (INTERIOR)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 047357
3 sets of Plans/Plot Plan
THE FgkLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF,QIZMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commissio
X �--
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
BP•2002-1008
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: 008.
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
ermit# BP-2002-1008
Project# JS-2001-1140
Est.Cost:$10000.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: O'Brien Construction 047357
Lot Size(sq.fQ: 0.00 Owner: OLENDER EDWARD JR&MICHELE P
Zoning�URB Awlicant. O'Brien Construction
AT: 355 BRIDGE ST - 1A & 1B
Applicant Address: Phone: Insurance:
75 Clayton Rd. X413 536-2564 Workers
Compensation
HOLYOKEMA01040-1543 ISSUED ON:
TO PERFORM THE FOLLOWING WORK:BUILD STAIRCASE TO CONNECT 2 BLDGS
(INTERIOR)
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NOR11W"' ON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy sin 104t�e
Fee Type: Receipt No: Date Paid: Check Amount:
Building 5/23/02 0:00:00 2053 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo